botulism in argentina case study answers

• Target audience
• INSTRUCTOR’S VERSION
• PART I - OUTBREAK DETECTION

In hypothesis-generating interviews with cases and other bus drivers, being a driver on the morning shift of the bus route and eating at the terminal home of the route were the only common exposures among cases. No cases of botulism occurred among bus drivers from the afternoon or evening shift of the route. Bus drivers from those shifts did not usually eat at the terminal home because it was only open for lunch.

Epidemiologic Case Studies

Botulism in argentina, target audience, available for download.

• Instructor's Version [PDF - 2 MB]
• Student's Version [PDF - 189 B]
• Versión para el instructor [PDF - 162 KB]
• Versión para el alumno [PDF - 59 B]

Public health practitioners with knowledge of basic epidemiologic concepts and experience in data collection and analysis.

Learning Objectives

After completing this case study, the student should be able to:

• Describe outbreak situations in which acute control measures should be undertaken.
• Communicate information on an outbreak or outbreak investigation and write a press release.
• Given the leading hypothesis(es) in an outbreak, develop a questionnaire.
• Given details on the origin, distribution, and preparation of an implicated food item, identify critical points for the control of contamination and microbial survival and growth.
• Discuss possible barriers to implementation of specific interventions following an outbreak investigation.
• Describe measures that can be used to monitor the success of an intervention.
• Describe the occurrence, signs and symptoms, and control of foodborne botulism.

Prerequisites

Successful completion of training in descriptive epidemiology, epidemic curves, measures of association, stratified analysis, study design, and outbreak investigation.

English and Spanish

Intermediate

3 to 4 hours

Continuing Education

Continuing education credits are not available for completing this case study.

Developed By

Jeanette K. Stehr-Green, MD developed this case study in close collaboration with staff from the Centers for Disease Control and Prevention:

• National Center for Infectious Diseases (Division of Bacterial and Mycotic Diseases/Foodborne and Diarrheal Diseases Branch and Food Safety Office)
• Epidemiology Program Office (Division of International Health)
• Public Health Practice Program Office (Division of Professional Development and Evaluation)

Original Investigation Team

The following individuals investigated the original outbreak of botulism in Argentina: Rodrigo G. Villar, Roger L. Shapiro, Silvina Busto, Clara Rive-Posse, Guadalupe Verdejo, Maria Isabel Farace, Francisco Rosetti, Jorge A. San Juan, Carlos Maria Julia, John Becher, Susan E. Maslanka, and David Swerdlow.

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• Page last reviewed: April 7, 2016
• Page last updated: April 7, 2016
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• Center for Surveillance, Epidemiology, and Laboratory Services ;
• Division of Scientific Education and Professional Development

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Botulism in Argentina

Based on an investigation of an outbreak of botulism among bus drivers in Buenos Aires in 1998.  

Objectives:

• Describe outbreak situations in which acute control measures should be undertaken
• Communicate information on an outbreak or outbreak investigation and write a press release
• Given the leading hypothesis(es) in an outbreak, develop a questionnaire
• Given details on the origin, distribution, and preparation of an implicated food item, identify critical points for the control of contamination and microbial survival and growth
• Discuss possible barriers to implementation of specific interventions following an outbreak investigation
• Describe measures that can be used to monitor the success of an intervention; Describe the occurrence, signs and symptoms, and control of foodborne botulism

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• v.9(9); 2017 Sep

Foodborne Botulism, I Only Had Nacho Cheese: A Case Report

Saad a choudhry.

1 Internal Medicine, University of California Davis

Muhammad Jahanzaib Anwar

2 Department of Internal Medicine, Rush University Medical Center

Muhammad Afzal

3 Pulmonary and Critical Care, Sutter Medical Center Sacramento

4 Intermountain Healthcare

A 32-year-old female presented to the emergency department with complaints of diplopia, followed by dyspnea, chest tightness, congestion, and dysphagia. The patient was resuscitated and initial investigations were done. Within a few hours of the admission, she started developing signs of respiratory failure and was intubated and placed on the mechanical ventilator. The patient denied any ingestion of exotic food, shellfish, raw meat, or raw fish. The patient also denied traveling to any exotic place or recent camping trips. The edrophonium tensilon test and lumbar puncture came out to be negative. The botulinum toxin test was positive, the patient was started on botulinum antitoxin, and the rest of symptomatic treatment was continued. The Centre for Disease Control (CDC) tracked the events related to the presentation and found she had eaten nacho cheese from a gas station the day before the appearance of the symptoms. A total of 10 cases were associated with this source within days and one death was reported.

Introduction

Foodborne botulism has been reported since as early as the eighteenth century when some ancient case reports described patients with a combination of dilated pupils and fatal muscle paralysis. The eighteenth century ended with some well-documented cases of outbreaks of “sausage poisoning” in Southern Germany that led to the need for early systematic botulinum toxin research. The first complete report with a complete description of the symptoms of foodborne botulism was reported between 1817 and 1822 by a German poet and district medical officer, Justin Kerner. At that time, he called it the “sausage poison” or the “fatty poison.” After 80 years of Kerner's work, in 1895, an outbreak of botulism in a Belgian town led to the discovery of the causative organism, Clostridium botulinum, by a professor of bacteriology at the University of Ghent―Dr. Emile Pierre van Ermengem. The Latin word for sausage is botulus, naming the bacterium as botulinum [ 1 ].

Recent studies and clinical experiences show that the most common source of foodborne botulism is often the canning of foods at home, which has a low acid content, such as green beans, corn, and beets. A common source of the illness in cold climate areas is fermented seafood. However, the use of oil-infused garlic, chili peppers, and baked potatoes, especially the foil-wrapped ones, are also found to be associated with the disease [ 2 - 3 ].

Case presentation

A 32-year-old female presented to the emergency department with a few hours' history of shortness of breath and weakness associated with chest tightness, congestion, hoarseness of voice, and difficulty swallowing. The patient had presented 24 hours earlier with the complaint of diplopia for one day. The patient denied any ingestion of exotic food, shellfish, raw meat, raw fish, or other foods generally associated with botulism. The patient also denied traveling to any exotic place or recent camping trips. The general workup, including biochemical and hematological investigations, came out to be normal except for a mildly decreased serum calcium (7.9 mg/dl). The magnetic resonance imaging (MRI) scan of the brain was also normal. That day, she was discharged with an outpatient consultation with neurology, but she continued to have persistent diplopia. After a few hours of admission, her breathing started to get worse, she was intubated, placed on mechanical ventilation, and was admitted to the intensive care unit (ICU). On examination, she had a symmetrical weakness in all four limbs, with more in the upper limbs compared to the lower limbs. The tensilon test was performed, which was negative. A lumbar puncture was performed, which also came out to be normal. Blood was sent to be tested for botulinum toxin. In the meantime, symptomatic treatment was started and disease control authorities were involved. Her weakness progressively increased and while she was being treated, another case arrived at the hospital with a very similar presentation. Four days later, the botulinum toxin test came positive and the patient was started on botulinum antitoxin and the rest of symptomatic treatment was continued. The Centre for Disease Control (CDC) tracked the events related to both these patients and found out that they both had eaten nacho cheese from a gas station the day before the appearance of their symptoms. A total of 10 cases were associated with this source within days and one death was reported.

Botulism is a rare, neuroparalytic, potentially life-threatening disease caused by toxins released by a gram-positive spore-forming bacteria, the Clostridium botulinum. The toxin blocks acetylcholine receptors at neuromuscular junctions, which result in a descending type of flaccid paralysis of voluntary muscles. The first symptoms to appear are ptosis, diplopia, and dysarthria, eventually leading to full-body paralysis, including of the respiratory muscles. While the affected patients are fully alert and their sensory system is intact throughout the period of illness, the disease is lethal due to the involvement of respiratory muscles, which might lead to respiratory failure and death [ 4 ]. Recovery usually takes weeks to months. The patients should be admitted to the ICU and the availability of mechanical ventilation should be ensured promptly if needed. The antitoxin should be administered early in the disease to decrease the natural course of the disease. The prognosis depends on early diagnosis and administration of the antitoxin, which may reduce the further deterioration of muscle weakness and the severity of the disease [ 5 ].

Foodborne botulism occurs when food containing preformed toxin is ingested. Clostridium botulinum spores are present in the environment [ 6 ] but the growth and development of the toxins only occur under specific conditions such as an anaerobic, low salt, and low acid environment. “Bacterial growth is inhibited by refrigeration below 4°C, heating above 121°C, high water activity, or acidity (pH <4.5)” [ 7 ]. “The toxin is destroyed by heating to 85°C for at least five minutes and spores are inactivated by heating to 121°C under pressure of 15–20 lb/in 2  for at least 20 minutes” [ 7 ].

Improper food handling practices are the most important cause of foodborne botulism in the United States as well as the rest of the world. Between 1990 and 2000, 160 cases of foodborne botulism were reported, in which 263 people were affected. According to the available data, eight deaths were recorded. Out of the 160 events, 58 occurred in Alaska, affecting 103 people. In most of these cases, the identified food source was fermented aquatic mammal tissue, beaver tails, seal flippers, and seal oil. Another source identified was fish and fish products such as fermented salmon head, white fish, and fish eggs [ 3 ].

In the rest of the states, including Hawaii, 102 events occurred, affecting 160 people. The food sources identified were diverse, including homemade canned foods, commercial foods, as well as restaurant-prepared foods [ 3 ]. But the reason remained―improper storage and preservation like inadequate refrigeration, use of sealed plastic bags and cans, and their exposure to sunlight and inability to heat the foods to a temperature that might kill the toxin. In this time period, there were 37 cases in which no identifiable food source could be attributed to the disease [ 3 ].

According to the CDC reports between 2001 and 2015, a total of 278 cases of foodborne botulism and 23 deaths were reported. One of the biggest outbreaks occurred in Ohio in 2015, in which 27 cases were reported and the food was confirmed to be potato salad/macaroni. Other outbreaks were caused by different home-canned foods like chili sauce, prune, beans, mushrooms, and other home-canned vegetables. During this time, there were 45 cases that could not be attributed to a specific food source [ 3 ].

Conclusions

Foodborne botulism, while rare, remains a public health emergency in the United States. Due to advances in medicine, it has become treatable and manageable but still poses a huge health problem due to its severity and epidemic potential. Botulism should always be included in the differential diagnosis of a patient with similar signs and symptoms, as early diagnosis could be critical in the management and, eventually, the prognosis of an affected patient. While taking the history of the patient, all foods should be taken into account just before the development of the symptoms rather than asking about the food sources generally associated with the disease. Even when there is no history of intake of foods associated with botulism, it should remain in the differentials until proven otherwise. Home-canned foods and Alaska native foods remain the leading cause of botulism in the United States. Restaurant-associated outbreaks continue to account for numerous illnesses. There should be a tight check over the packaging of known foods that have the potential to thrive Clostridium botulinum, and all such facilities should be federally regulated. All suspected cases of botulism should be reported to public health authorities immediately. Prompt epidemiologic investigation helps prevent additional cases and can identify new risk factors for intoxication.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.

Human Ethics

Consent was obtained by all participants in this study

Botulism case study - Student Guide

This case study is based on a real outbreak in Argentina published in JAMA, 1999; 281: 1334-1340 by Villar R, Shapiro R et al.. It is based also on a training material prepared by Jeannette K. Stehr-Green at the CDC, Atlanta, Georgia, USA.

Because of didactical purposes, in this case study, we altered several aspects in order to meet the SAPUVETNET II  project teaching  objectives.

Learning objectives.

The student should be able to:

• Describe outbreak situations in which acute control and prevention measures should be undertaken.
• Give details on the origin , preparation and distribution  of food items implicated.
• Identify critical control points  for the control of contamination , microbial survival and growth.
• Describe the occurrence, signs and symptoms  and control of foodborne botulism.  Required knowledge: basic knowledge of epidemiology, types of studies, food-borne diseases investigation outbreaks.
• Describe measures to be adopted and possible barriers to  implement them.

Introduction

Food borne botulism is a severe illness that results from the ingestion of a preformed toxin produced by a bacterium  Clostridium botulinum . Botulinum neurotoxin  is a lethal poison. Death can occur in up to 50% of untreated cases but can be reduced  at less than 10% with respiratory assistance and  antitoxin administration. Outbreaks of botulism have been linked to improperly  home preserved vegetables, commercial canned vegetables, meats, sausages, fish products and sea foods. Also cheese and yogurt. Incubation period of the disease is generally 18 to 36 hours since food intake but illness could occur from 6 hrs to 10 days.

Gastrointestinal and neurological initial symptoms may be followed by disturbances in speech, swallowing and peripheral muscle weakness. If respiratory muscles are involved, death may result. Many physicians are unfamiliar with it presentation. As a result patients with botulism can be misdiagnosed ( stroke, myasthenia gravis, Guillain-Barré syndrome) delaying the administration of antitoxin and increasing the mortality rate among cases.

The outbreak 

 On January , a physician at a Hospital informed Health authorities about two possible cases of botulism. Both patients, males, drivers in the same company  presented double vision, difficulty in swallowing and respiratory problems. When the physician suspected botulism he collected stool specimens of  both patients to test for botulinum toxin.

Question1 : What are the major concerns raised by these two possible cases of botulism in the city?

Question2 : How might you find out if there are other cases of botulism associated with that cases?

 Eight additional patients with symptoms were identified. In some cases the working diagnoses was myasthenia gravis and stroke. Toxin were identified in 3 of the 10 cases.

All patients were drivers, males, worked for the same bus company and drove the same route. All had eaten at a home located at the terminal stop of the bus route open only for lunch. Approximately 58 drivers worked in that route: 22 in the morning, 21 in the afternoon and 15 in the evening.

Investigators considered that the outbreak was limited to the morning shift and lunch meals.

Question 3: Would you initiate any control measures at this time? What criteria would you consider in implementing control measures so early in the investigation.?

Designing an epidemiological study to test the hypothesis.

Investigators undertook a retrospective cohort study among bus drivers who drove in the morning in the bus route. Data were collected from January 15 to 19. A probable case was defined as with neurological symptoms ( blurred vision, double vision, drooping eyelids, problems swallowing) starting the onset of symptoms between January 5 and 15). A confirmed case was positive for botulinum toxin at the laboratory.

The comparison group consisted of all bus drivers from the morning shift who had no symptoms.

Investigators developed a structures questionnaire for the epidemiological study.

Question 4: What general types of information would you include in the questionnaire?.

Question 5 : Using information on foods served at the terminal stop home from January 3 to January 7 (hot dog, matambre , mate, salami, sauce, solid ham) draft questions for food exposure for this study.

Investigators conducted interviews with each of the drivers of the morning shift of the bus route to complete the questionnaires. Healthy and ill drivers.

They prepared a summary table for healthy and another for ill drivers.

An x was marked for each healthy and ill people who had eaten an specific meal and a – if  the driver didn’t eat that specific meal.

They calculated the total drivers who had eaten or not each of the food implicated.

Table Summary  Diseased  10

Table Summary  Healthy 12

Question 6 : Make a calculation of the percentage of people that having eaten an specific meal were ill.

Prepare an attack rate table considering that those who eat and get ill or not.

Attack rate: (exposed: not exposed) x 100

Complete the Table 

Type of food

The attack  rate is a measure of the INCIDENCE of people who get ill in a given population. The difference between the data of people who had eaten an specific product give us an idea about the food implicated.

Question7: observing the tables determine which of the meals  presented higher difference between people who eat and who didn’t  that meal.

Question8 : Which food presented an higher Relative Risk? What is it Signification?

Environmental studies and food investigation.

Matambre is a traditional Argentine dish prepared from meat, vegetables, spices and boiled eggs . It is cooked for several hours and consumed cold.

The matambre was purchased at a local vendor. The objective of this part of the study was to identify critical points where the implicated food could have became contaminated or microbial growth in food could have occurred.

The factors that commonly contribute to outbreaks of food borne diseases are: Deficient time-temperature in cooking, deficient hygiene, raw foods contaminated, infected food handler, slow cooling, cross contamination, preparation too far in  advance, environment that provides favorable conditions for pathogen growth.

Question 9 : What type of activities it should be take into account to investigate the food-handling practices for the matambre which were most likely to contribute to the development of botulism.

Clostridium  botulinum is a spore-forming obligate anaerobic bacterium (it cannot grow in the presence of Oxygen). The spores are widespread in soil and dust worldwide. The toxin is produced in improperly canned, low-acid or alkaline foods. The toxin is destroyed by boiling: inactivation of spores requires much higher temperatures.

In this outbreak the home at the terminal stop was not formally licensed or equipped as a restaurant.

The refrigerators were over 10ºC. It was not temperature records.

Some customers reported that the matambre had recently been sold at reduced prices because of power outages.

The meat was rolled up round the vegetables and eggs. The meat roll was placed into individual steel pans and immersed in water heated to 70-80ºC for 4 hours. This conditions weren’t sufficient for the destruction of spores of C.botulinum . After cooking the matambre was placed in plastic wrap, squeezed out the air and sealed the plastic with heat. After that it was allowed to cool, placed in a refrigerator and stored for up to 2 weeks before being sold to consumers or supermarkets.

Question 10 : Identify the food handling practices for the matambre which were most likely to contribute to the development of botulism.

Question11 : What control measures would you take at this step?

Case study developed by the member SAPUVETNET II – University of Salvador, Pilar-Buenos Aires (Argentina)                                      Contact: Dora Dobosch E-mail: [email protected]

Food-borne botulism in Argentina

Affiliation.

• 1 Department of Microbiology and Parasitology, School of Medicine, University of Buenos Aires, Argentina.
• PMID: 19759486
• DOI: 10.3855/jidc.120

Botulism is a severe neuroparalytic disease caused by Clostridium botulinum toxins. Although the disease is uncommon it is a cause of great concern due to its high rate of mortality. Food-borne outbreaks of botulism occur worldwide and require immediate public health attention and acute care resources. Analysis of outbreaks showed that the food products most often involved were fermented fish products in Alaska; home-canned food, oil preservation and restaurant sauce in the rest of the United States (US) and in London and; and home-canned vegetables, airtight packed food with inappropriate refrigeration, and aerosols in Argentina. The diagnosis is based only on clinical findings matching the disease and previous exposure to suspicious food. Botulism must be immediately identified as even one case suggests the start of an epidemic and should be treated as a public health emergency. Therefore, the purpose of the following review is to recognize the risks associated with the consumption of potentially dangerous foods, and to encourage prevention by seeking to make all public health professionals aware of the dangers of this potentially lethal disease.

Publication types

• Argentina / epidemiology
• Botulism / diagnosis
• Botulism / epidemiology*
• Botulism / prevention & control
• Clostridium botulinum / isolation & purification
• Food Microbiology
• Foodborne Diseases / diagnosis
• Foodborne Diseases / epidemiology*
• Foodborne Diseases / prevention & control

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Foodborne disease outbreak investigation, epidemiologic case study. Botulism in Argentina

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